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Supplement D: Community Containment Measures, Including Non-Hospital Isolation and Quarantine

Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2/3

Contacts of SARS patients can be managed by use of a range of interventions, all of which are designed to facilitate early recognition of illness in persons at greatest risk of becoming infected and thereby to prevent transmission to others. Whereas many of these interventions are applied individually to persons identified as contacts of a person with possible or known SARS-CoV disease, others are applied to larger groups of persons, or communities, who share a similar risk of exposure. The interventions include the following:

Passive Monitoring

Definition

The contact is asked to perform self-assessment at least twice daily and to contact authorities immediately if respiratory symptoms or fever occur

Application

Situations in which 1) the risk of exposure and subsequent development of disease is low, and 2) the risk to others if recognition of disease is delayed is also low.

Partners

Forms/Templates

Active Monitoring without Explicit Activity Restrictions

Definition

A healthcare or public health worker evaluates the contact on a regular (at least daily) basis by phone and/or in person for signs and symptoms suggestive of SARS-CoV disease

Application

Situations in which 1) the risk of exposure to and subsequent development of disease is moderate to high, 2) resources permit close observation of individuals, and 3) the risk of delayed recognition of symptoms is low to moderate

Benefits

Places few constraints on individual liberties

Challenges

Requires adequate staffing

Requires a system to track information and to verify monitoring
and appropriate actions based on findings

Resources Required

Trained staff to provide in-person and/or telephone evaluations

Contingency plans for managing noncompliant persons

Contingency plans for rapid isolation of persons who develop
symptoms

Hotline to notify authorities about symptoms or needs

Partners

Professional and lay healthcare workers to perform evaluations on behalf of the health department

Possible need for law enforcement to assist with
management of noncompliant persons

Forms/Template

Active Monitoring with Activity Restrictions (Quarantine)

Definition

The contact remains separated from others for a specified period (generally 10 days after potential exposure), during which s/he is assessed on a regular basis (in person at least once daily) for signs and symptoms of SARS-CoV disease. Persons with fever, respiratory, or other early SARS-CoV symptoms (see MMWR 52(49):1202-1206) require immediate evaluation by a trained healthcare provider. Restrictions may be voluntary or legally mandated; confinement may be at home or in an appropriate facility.

No specific precautions are required for those sharing the household with a person in quarantine as long as the person remains asymptomatic. However, because onset of symptoms may be insidious, it may be prudent to minimize interactions with household members during the period of quarantine.

Application

Situations in which the risk of exposure and subsequent development of disease is high and the risk of delayed recognition of symptoms is moderate

Benefits

Reduces risk of spread from persons with subacute or subclinical presentations or from delayed recognition of symptoms

Challenges

Infringes on personal freedom of movement

May lead to a feeling of isolation from family and friends

May lead to loss of income or employment

Requires plans/protocols for provision of essential services

Requires plan for provision of mental health support

Risk of noncompliance, particularly as duration increases

May require enforcement for noncompliance

Resources Required

Staff for monitoring and evaluation

Appropriate facility if home setting is unavailable or inadequate
Staff, funding, goods for provision of essential services

Hotline for notification of symptoms or personal needs

Mechanisms to communicate with family members outside the household or facility

Mental health and social support services

Delivery systems for food and other essential supplies

Partners

Professional and lay healthcare workers to perform assessments on behalf of the health department

Community volunteers/workers to assist with provision of essential services

Potential need for law enforcement to assist with noncompliant persons

Forms/Templates

Checklist for active monitoring

Template for recording results of clinical evaluation

Checklist and guidelines for evaluation of homes for quarantine

Checklist and guidelines for evaluation of community-based sites for quarantine

Guidelines for monitoring compliance with home quarantine

Guidelines for monitoring compliance with quarantine in community-based facilities

Forms for recording compliance with quarantine

Examples

Working Quarantine

Definition

Persons are permitted to work but must observe activity restrictions while off duty. Monitoring for fever and other symptoms before reporting for work is usually required. Use of appropriate PPE while at work is required.

Focused Measures to Increase Social Distance

Definition

Intervention applied to specific groups, designed to reduce interactions and thereby transmission risk within the group. When focused, the intervention is applied to groups or persons identified in specific sites or buildings, most but not necessarily all of whom are at risk of exposure to SARS-CoV

Application

Groups or settings where transmission is believed to have occurred, where the linkages between cases is unclear at the time of evaluation, and where restrictions placed only on persons known to have been exposed is considered insufficient to prevent further transmission

Benefits

Applied broadly, reduces the requirement for urgent evaluation of large numbers of potential contacts to determine indications for activity restrictions.

May enable reductions in transmission among groups of persons without explicit activity restrictions (quarantine)

Challenges

May be difficult to solicit cooperation, particularly if popular buildings are closed or popular events are cancelled

Examples

Community-Wide Measures to Increase Social Distance

Definition

Intervention applied to an entire community or region, designed to reduce personal interactions and thereby transmission risk. The prototypical example is implementation of a “snow day,” in which offices, schools, transportation systems are cancelled as for a major snowstorm.

Application

All members of a community in which 1) extensive transmission of SARS-CoV is occurring, 2) a significant number of cases lack clearly identifiable epidemiologic links at the time of evaluation, and 3) restrictions on persons known to have been exposed are considered insufficient to prevent further spread

Benefits

Reduces need for urgent evaluation of large numbers of potential contacts to determine indications for activity restrictions

May enable reductions in transmission among groups without explicit activity restrictions (quarantine)

“Snow days” are familiar concepts and thus easy to implement on short notice

When an entire community is involved, requires cooperation with neighboring jurisdictions that may not be using a similar intervention, particularly in situations where persons live in one city and work in another and only one locale is affected by the intervention.

Generally relies on passive monitoring

Resources Required

Communication outlets

Enforcement

Resources for passive monitoring

Hotlines and other communication systems to report symptoms and obtain follow-up instructions

Examples

Widespread Community Quarantine, Including Cordon Sanitaire

Definition

Legally enforceable order that restricts movement into or out of the area of quarantine of a large group of people or community; designed to reduce the likelihood of transmission of SARS-CoV among persons in and to persons outside the affected the area. When applied to all inhabitants of an area (typically a community or neighborhood), the intervention is referred to as cordon sanitaire (sanitary barrier).

Application

All members of a group in which 1) extensive transmission is occurring, 2) a significant number of cases lack identifiable epidemiologic links at the time of evaluation, and 3) restrictions placed on person known to have been exposed are considered insufficient to prevent further spread. Widespread quarantine is unlikely to be necessary because other less restrictive measures (e.g., snow days) may be equally effective.

Benefits

Reduces need for urgent evaluation of large numbers of potential contacts to determine indications for activity restrictions

Challenges

Most extreme of the potential containment measures

May be controversial because of infringement on personal liberties

May be difficult to solicit cooperation for extended periods, particularly if the rationale is not readily apparent or was not clearly explained

Requires excellent communication mechanisms to inform affected persons and to maintain public confidence in the appropriateness of the chosen course of action

May need to provide replacements for affected activities (e.g., school, essential service providers)

Must address mental health and financial support for affected population

When an entire community is involved, requires cooperation with neighboring jurisdictions that may not be using a similar intervention, particular in situations where persons live in one city and work in another and only one locality is affected by the intervention